Ex-post-facto analysis of competitive employment outcomes for individuals with mental retardation: National perspective

Authors: 
Morgan, L., Leatzow, A., Clark, S., & Siller, M.
Year Published: 
2004
Publication: 
Mental Retardation
Volume: 
42
Number: 
4
Pages: 
253-262
Publisher: 
American Association on Mental Retardation
Background: 

Employment outcomes have often been used as a benchmark of vocational rehabilitation success. Not until the Rehabilitation Act of 1973, were states required to target individuals with significant disabilities for services using an order of selection process. Because of the functional differences that exist between individuals with mild, moderate and significant cognitive disabilities, rehabilitation counselors must be aware of the types of services most needed and those services that more often result in high quality employment outcomes for each target group.

Purpose: 

The purpose of this study was to provide a snapshot to generate new knowledge that rehabilitation counselors can apply to enhance competitive employment outcome placements for individuals of varying abilities. In addition, the purpose of the study was to identify disparities in the proportions of competitive job placements between individuals with mild, moderate, and significant cognitive disabilities.

Setting: 

This study included individuals with disabilities served by multiple vocational rehabilitation agencies in various settings.

Sample: 

The study sample included all consumers with cognitive disabilities closed into Status 26 during fiscal year 1998 in the RSA-911 national database maintained by the Rehabilitation Services Administration. This included a total of 28,565 consumers: mild (n = 17,033, 60%), moderate (n = 9,784, 34%), severe/profound (n = 1,748, 6.1%).

Data Collection: 

The data was obtained from the individual client closure reports and RSA-911 national data tape, provided by the Rehabilitation Services Administration (RSA). The authors used two tests of statistical significance: chi-square and logistic regression analysis. Chi-square analysis was conducted for type of mental retardation and work status at closure. In addition the authors conducted a post hoc pairwise comparisons (2 x 2 chi-square) for mild by moderate, mild by severe/profound and moderate by severe/profound. To guard against Type I errors, the authors used the Bonferroni technique, which resulted in an adjusted alpha of .003. Then, the authors used logistic regression analysis to evaluate the linear relationship between vocational rehabilitation services and work status at closure. Then, chi-square tests were used to evaluate the proportions of significant vocational rehabilitation services received by consumers with mild, moderate, or severe/profound cognitive disabilities. Then, the relationship between type of cognitive disability and work status at closure were evaluated for consumers who received vocational rehabilitation services. Those consumers who had not received VR services were then eliminated from the sample. The desktop version of SPSS for Windows, version 11.5 was used in this analysis.

Intervention: 

The intervention was vocational rehabilitation services.

Control: 

There was no control or comparison condition.

Findings: 

The majority of the individuals in the population were Caucasian (73%). Assessment, adjustment, counseling, job-finding services, and job-placement services were received by 81%, 34%, 78%, 60% and 58%, respectively. Analysis of the data found that 8%5 of the participants were closed into competitive jobs following vocational rehabilitation intervention. Consumers with mild mental retardation were significantly more likely to achieve competitive jobs when compared to those with moderate or severe/profound cognitive disabilities. In addition, individuals with moderate cognitive disabilities were significantly more likely to be placed into competitive jobs compared to those with severe/profound disabilities. The odds of obtaining competitive employment for consumers who received job placement services was 2.05 times the odds for those not receiving those services. The odds of obtaining competitive employment for consumers who received counseling were 1.52 times the odds of those who did not receive counseling. The odds of obtaining competitive employment for consumers who received business and vocational training were 2.14 times the odds of those who did not. However, consumers with mild mental retardation were provided with business and vocational training at a significantly higher proportion when compared to those with moderate and severe/profound disabilities. Consumers with moderate mental retardation were no more likely to receive counseling services than those with mild cognitive disabilities. However, consumers with severe/profound cognitive disabilities were less likely to receive counseling services than those with mild/moderate disabilities. Consumers who received job placement services with mild cognitive disabilities achieved competitive jobs at a significantly higher proportion than those with moderate or severe/profound mental retardation. In addition, consumers with moderate cognitive disabilities were significantly more likely to achieve competitive jobs than individuals with severe/profound disabilities. Consumers with mild cognitive disabilities who received business and vocational services achieved competitive jobs at a significantly higher proportion than those with moderate and severe/profound cognitive disabilities. Consumers with mild disabilities who received counseling achieved competitive jobs at a significantly higher proportion when compared to those with moderate and severe/profound disabilities. In addition, consumers with moderate cognitive disabilities were more likely to achieve competitive employment when compared to consumers with severe/profound disabilities.

Conclusions: 

Consumers with Moderate or severe/profound cognitive disabilities were closed into competitive employment at a significantly lower rate than those with mild cognitive disabilities. Consumers who were provided with business and vocational training, counseling, and job-placement services were significantly more likely to achieve competitive jobs. A significantly lower proportion of these services were provided to consumers with severe/profound cognitive disabilities.

The authors concluded that the significantly higher proportion of consumers with mild cognitive disabilities achieving competitive employment could be related to the specific services they more often receive. Perhaps consumers with mild disabilities are more likely to be provided job-placement services as opposed to those with severe/profound cognitive disabilities. The authors ask the questions: Why do consumers with mild or moderate cognitive disabilities more likely to receive job placement and counseling services compared to those with severe/profound disabilities? They propose that too much attention may be given to assessment/testing results and other nonrelevant dimensions that could prohibit the provision of effective services. They also propose that there may be a subjective belief that places a lesser value on the overall potential of individuals with significant cognitive disabilities. Counselors may believe that consumers with severe/profound cognitive disabilities are more difficult to place. Their expectation of successful employment outcomes may result in less significant placement efforts for this population.

The authors state that their findings raise questions that could not be answered through the RSA-911 database. The database does not provide information on reasons for the provision of certain services to consumers with mild, moderate, or severe/profound cognitive disabilities. The database does not contain information on Counselors' perceptions of service effectiveness or how they provide the specific services. Finally, the small proportion of individuals with severe/profound cognitive disabilities raises an important question about the decision-making process counselors use to determine if a consumer can benefit from vocational rehabilitation services.

URL: 
https://www.ncbi.nlm.nih.gov/pubmed/15230653
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Work, recovery and comorbidity in schizophrenia: A randomized controlled trial of cognitive remediation

Authors: 
McHugo, G., Drake, R., & Becker, Dl.
Year Published: 
2009
Publication: 
Schizophrenia Bulletin
Volume: 
35
Number: 
2
Pages: 
319-335
Publisher: 
Oxford University Press
Background: 

A common theme that cuts across all definitions of recovery is work. Work is valued by most and it enables on to make a contribution to society and offers the promise of liberating consumers from financial dependence on others. In recent years, a recovery paradigm has emerged that offers a guiding vision for self-empowerment, treatment, and rehabilitation for individuals with schizophrenia and comorbid problems such as: cognitive impairment,9 substance abuse,10 and medical disorders. This study addressed the impact of comorbidity on recovery of work functioning and response to vocational rehabilitation, described strategies for minimizing its effects, and provided data from a new study targeting the problem of cognitive impairment in order to improve employment outcomes.

Purpose: 

The purpose of the study is to evaluate the impact of adding cognitive remediation to vocational rehabilitation to determine the impact on comorbid substance abuse and medical disorders on work outcomes and response to the treatment program.

Setting: 

The study took place in a vocational rehabilitation program associated with an urban medical center.

Sample: 

The study included 34 participants who were 18 years or older, had severe mental illness, expressed an interest in work, had a history of being fired or quitting employment prior to locating new work. Participants received either vocational rehabilitation plus cognitive retraining or Vocational rehabilitation only.
In both groups, the majority of subjects were male (61% and 56%) black (61% and 63%) and had never been married (78% and 75%). The primary diagnosis was Schizophrenia (75% and 60%) and most had a comorbid disorder (67% and 81%). The mean age of the group members was (46 and 42 years).

Data Collection: 

Referrals were made by therapists and work services personnel. Those interested had a baseline assessment scheduled. Consumers were not paid for assessments. Following completion of the assessments, consumers were randomized to either vocational rehabilitation alone (VR) or vocational rehabilitation and cognitive remediation (VR and CR)using a computer program. The examiners compared the groups at baseline on the demographic, clinical, and cognitive measures using t-tests (continuous variables) and v2 analyses (categorical variables). Next they computed the percentage of consumers who were exposed to the cognitive remediation program, as completing 6 or more cognitive remediation sessions, the average number of sessions completed, and the number of weeks to complete them.

Then to evaluate changes over the treatment period in cognitive functioning and clinical variables, they performed a series of analyses of covariance (ANCOVAs), with the cognitive/symptom measures at posttreatment as the dependent variables, the cognitive/ symptom measures at baseline as the covariate, and treatment group as the independent variable. Finally they looked at work outcomes. Because continuous work outcomes were highly positively skewed, main treatment effects were evaluated by performing Mann-Whitney U tests comparing the 2 treatment groups on wages earned and hours and weeks worked. To evaluate whether substance abuse directly influenced vocational outcomes or interacted with treatment group, separate analyses were performed for current drug-use disorder and alcohol-use disorder. For these analyses, the work variables were log transformed to minimize skew. For each series of analyses, analysis of variance were performed with current drug-use disorder (or current alcohol-use disorder), treatment group, and their interactions as the independent variables and the work outcomes as the dependent variables. The main effect for drug-use disorder (or alcohol-use disorder) in these analyses was a test of whether the disorder had an overall impact on vocational outcomes, whereas the drug-use disorder (or alcohol-use disorder) by treatment group interaction effect was a test of whether the outcomes of the treatment groups differed significantly as a function of the disorders.

Intervention: 

The intervention was adding cognitive remediation to a hybrid vocational rehabilitation program that combined paid internship jobs with supported employment.

Control: 

Participants were randomly assigned to either vocational rehabilitation alone or vocational rehabilitation and cognitive remediation using a computer-generated randomization program.

Findings: 

Statistical tests comparing consumers assigned to VR only or VR and CR indicated no significant differences in any demographic, diagnostic, or baseline clinical or cognitive performance measures.

The results of the ANCOVAs comparing changes over time in cognitive functioning and symptoms between consumers who received cognitive remediation and those who did not were summarized. Significant improvements favoring cognitive remediation were found for several cognitive measures. Results of the Mann-Whitney U tests comparing work outcomes for the 2 groups indicated that the VR and CR group worked significantly more internship weeks and hours and earned more wages than the VR-only group.

The VR and CR group also worked significantly more weeks than VR only, and there was a trend for them to earn more wages, although hours
worked did not differ between the groups. Number of weeks or hours of competitive work did not differ between the 2 groups nor did wages earned. Overall rates of competitive rates were 39% for the VR and CR group vs 31% for the VR-only group, which did not differ significantly. Analyses of relationship of substance-abuse disorder and medical comorbidity focused on total (log transformed) hours worked for each vocational outcome. Alcohol-use disorder was marginally significantly related to total hours worked with the absence of current alcohol-use disorder associated with more hours worked compared with the presence of an alcohol-use disorder. Drug-use disorder was also related to total hours worked, with absence of current drug-use disorder associated with more hours worked compared with the presence of a drug-use disorder.

There were no interactions between either alcohol or drug-use disorder and treatment group, suggesting that the addition of cognitive remediation to vocational services was just as helpful in the consumers with a substance-use disorder as those without. A similar analysis of total hours worked comparing consumers with high levels of medical comorbidity to those with low levels indicated that both the main effect for medical comorbidity and the interaction with treatment group were not significant. Thus, consumers with higher medical comorbidity burden appeared to have comparable vocational outcomes compared with those with less such burden. For the VR-only group, Spearman correlations between overall cognitive performance at baseline and total work over the study period were significant for total hours worked and wages earned and marginally significant for number of weeks worked, whereas for the VR and CR group, none of these correlations were significant Thus, cognitive performance at baseline was more predictive of work in the study for those in the control group than those in the cognitive remediation group.

Conclusions: 

Providing cognitive remediation in addition to vocational rehabilitation can improve cognitive functioning and employment outcomes for individuals with severe mental illness. Comorbid substance abuse impacts work outcomes while medical comorbidity does not. More research is needed to evaluate the impact of comorbidity and their interaction on treatment. More research is needed to evaluate the impact of comorbidity on work functioning in VR and its interaction with cognitive remediation.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/19269925
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Vocational rehabilitation service patterns related to successful competitive employment outcomes of persons with spinal cord injury

Authors: 
Martin, D. J., Arns, P. G., Batterham, P. J., Afifi, A. A., & Steckart, M. J.
Year Published: 
2008
Publication: 
Journal of Vocational Rehabilitation
Volume: 
28
Number: 
1
Pages: 
1-13
Publisher: 
IOS Press
Background: 

It is well documented in the literature that the employment rate of people with spinal cord injuries (SCI) decreases drastically after their injuries. Because of the importance of work to the physiological and psychological health and well being of persons with a disability, considerable research efforts have been devoted to studying the employment problems of persons with a spinal cord injury. Over a half of a million individuals are served by state vocational rehabilitation agencies each year, making it possible to study a large number of persons with SCI who are living in the community.

Purpose: 

To examine the effect of demographic, work disincentives, and service variables on employment outcomes of persons with spinal cord injury in state vocational rehabilitation agencies.

Setting: 

This study included individuals with SCI served by multiple vocational rehabilitation agencies in various settings.

Sample: 

10,901 persons with spinal cord injury whose cases were closed either as employed (54%) or not employed (46%) by state vocational rehabilitation agencies in the fiscal year 2001.

Data Collection: 

An ex post facto design, using data mining as a statistical analysis strategy. Data was taken from the RSA-911 report for all the persons with SCI closed by State Vocational Rehabilitation agencies in 2001. A chi-squared automatic interaction detector (CHAID) based data mining analysis was used to identify the strongest associations between predictors (VR services) and the outcome variable (employment outcomes).

Intervention: 

The interventions were the range of Vocational Rehabilitation Services received by the study sample of persons with a Spinal Cord Injury. These services included, but were not limited to, rehabilitation engineering, personal assistance services, assistive technology services, job placement, counseling and guidance, and assessment services.

Findings: 

The CHAID data mining analysis revealed that job placement services, work disincentives, and case expenditures as the most important predictors of employment outcomes. In addition, physical restoration, substantial counseling, and assistive technology services all led to positive employment outcomes. Importantly, the CHAID analysis segmented the sample into 45 mutually exclusive homogeneous end groups, with a wide range of employment outcomes. The CHAID analysis indicated that demographic variables interacted with rehabilitation services to affect employment outcomes.

Conclusions: 

The results confirmed substantial counseling, assistive technology, and job placement and support services are important to the return-to-work success of persons with SCI.

URL: 
http://content.iospress.com/articles/journal-of-vocational-rehabilitation/jvr00399
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Supported employment for middle-aged and older people with schizophrenia.

Authors: 
Twamley, E. W., Padin, D. S., Bayne, K. S., Narvaez, J. M., Williams, R. E., & Jeste, D. V.
Year Published: 
2008
Publication: 
American Journal of Psychiatric Rehabilitation
Volume: 
11
Number: 
1
Pages: 
76-89
Publisher: 
Routledge
Background: 

Older people with severe mental illness are frequently assumed to be incapable of returning to work and are not actively recruited to participate in work rehabilitation programs. However, just as healthy older people are working well past traditional retirement age, many older people with schizophrenia want to work. However, very few vocational rehabilitation programs target older clients with psychiatric illness.

Purpose: 

This study examined employment outcomes among adults with schizophrenia or schizoaffective disorder in a 12-month randomized controlled trial comparing two work rehabilitation programs: Individual Placement and Support (IPS; a supported employment model) and conventional vocational rehabilitation.

Setting: 

The setting was an outpatient clinic in San Diego, California and various places of employment.

Sample: 

The study sample included 50 participants,30 men and 20 women who were 45 years or older, had a DSM-IV (American Psychiatric Association, 1994) diagnosis of schizophrenia or schizoaffective disorder, and were receiving their psychiatric care at an outpatient clinic. Twenty subjects were diagnosed with schizophrenia, and 30 were diagnosed with schizoaffective disorder. They were referred by state vocational rehabilitation.

Data Collection: 

The following techniques were used t-tests, chi-square, logistic regression, and repeated measures ANOVA to analyze the data. Alpha for significance was set at p < .05, and all tests were two-tailed. Cohen's d effect sizes to provide estimates of the magnitude of effects was also calculated.

Intervention: 

The intervention was the Individual Placement and Support (IPS) model of supported employment. This a systematic approach to helping people with severe mental illness achieve competitive employment. It is based on eight principles: eligibility based on client choice, focus on competitive employment, integration of mental health and employment services, attention to client preferences, work incentives planning, rapid job search, systematic job development, and individualized job supports. Systematic reviews have concluded that IPS is an evidence-based practice.

Control: 

Conventional vocational rehabilitation programs use a train-then-place approach, emphasizing prevocational training classes and volunteer, transitional, or trial employment before seeking competitive work (i.e., employment in the community at prevailing wages).

Findings: 

Compared with Conventional Vocational Rehabilitation, Individual Placement and Support resulted in statistically better work outcomes, including attainment of competitive employment, number of weeks worked, and wages earned. Cohen's d effect sizes for these variables were medium to large (.66-.81). Treatment group predicted future attainment of competitive work, but demographic and clinical variables (e.g., age, gender, ethnicity, education, illness duration, and medication dose) did not predict employment outcomes. Participants who obtained competitive employment reported improved quality of life over time compared to those who did not.

Conclusions: 

These findings suggest that for middle-aged and older clients with schizophrenia, supported employment results in better work outcomes than does conventional vocational rehabilitation. Furthermore, age was not significantly associated with attainment of competitive work. Finally, the therapeutic value of work is reflected in improved quality of life.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/19212460
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Effect of job skills training on employment and job seeking behaviors in an American Indian substance abuse treatment sample

Authors: 
Fong, C. J., Murphy, K. M., Westbrook, J. D., & Markle, M. M.
Year Published: 
2010
Publication: 
Journal of Vocational Rehabilitation
Volume: 
33
Number: 
3
Pages: 
181-192
Publisher: 
IOS Press
Background: 

Employment problems are often significant in American Indian communities. Barriers such as historically high unemployment rates or a lack of job finding skills may contribute to lower than expected job skills and career development. Likewise, unemployment is high for those with substance abuse disorders. There is little empirical research addressing interventions for American Indians with substance abuse disorders for improving employment status.

Purpose: 

The purpose of this study was to implement the Job Seekers Workshop (JSW), a 12-hour job search-training program, in an American Indian addiction treatment program, and to evaluate its outcomes in comparison to the Job Interview Videos (JIV), a 40-minute two-part video.

Setting: 

The study setting was the Na Nizhoozhi Center (NCI) in Gallup, NM. The NCI is a 150-bed facility that provides culturally specific treatment programs to meet the needs of American Indian.

Sample: 

The study sample consisted of 102 individuals with American Indian heritage who were drug and/or alcohol dependent, 18 years of age or older, enrolled at NCI for at least 10 days, categorized as either unemployed (i.e., not having worked at all for the month prior to study recruitment) or underemployed (i.e., having worked no more than 20 hours/week in any
given week during the past month), and interested in obtaining a job. The majority were Navajo males.

Data Collection: 

The measures included several standardized instruments measuring addiction severity, current use of substances, reading ability, and life experiences. Employment information was captured using the Timeline Follow Back for Employment (TLFB-E). Two variables served as primary outcomes: 1) time (number of days) to employment, either a new taxed job or enrollment in a job-training program within the follow-up period, and 2) total hours either working or enrolled in a job-training program within the time period. Time to employment and time to enrollment in a job-training program were tested using the Cox Regression procedure. Analyses addressing the number of participants reporting employment or enrollment in a training program were conducted using Chi-square tests. Analyses focused on hours spent working or in training were conducted using an analysis of variance (ANOVA). Comparisons based on repeated measures over time were tested using multivariate repeated measures analyses of variance (MANOVA).

Intervention: 

Two interventions were tested. First, the Job Seeker‚ Workshop (JSW) is a standardized 12-hour job search-training program designed to increase job-seeking skills, particularly interviewing. The program consists primarily of focused, individual instruction with videotaped feedback for group discussion. The Job Interviewing Video (JIV) is a 40-minute instructional video related to answering job interview questions, including difficult questions.

Control: 

The study used a two-group comparison design.

Findings: 

There were no significant differences between the JSW and JIV groups at baseline, nor were there differences in completion time of the program or time to employment at either three or six months following completion or in job-seeking behaviors. A significant difference was found on enrollment in a training program, with more participants who were involved in the JIV intervention enrolled in a training program than in the JSW intervention. Satisfaction was rated relatively high for both programs. There were also no differences in substance use post-completion, with both groups reporting reduced use.

Conclusions: 

Although both groups showed some gains in employment from baseline to follow-up, overall rates of employment remained low at follow-up, averaging less than 50 total hours worked within the first three months following randomization. However, positive changes were observed related to substance use. Significant differences in the primary outcomes were not detected between the JSW and JIV interventions

URL: 
http://content.iospress.com/articles/journal-of-vocational-rehabilitation/jvr526
NIDILRR Funded: 
Peer Reviewed: 
Yes

Predictors of successful return to work from HIV-related disability

Authors: 
Drake, R. E. & Bond, G. R.
Year Published: 
2004
Publication: 
Journal of HIV/AIDS and Social Services
Volume: 
3
Number: 
3
Pages: 
89-96
Publisher: 
Journal of HIV/AIDS and Social Services
Background: 

Many individuals with HIV/AIDS experience periods of unemployment as their physical symptoms increase. However, some in treatment do continue or return to employment.

Purpose: 

The purpose of this study was to compare a sample of individuals with HIV/AIDS who successfully return to employment and those that do not. The factors included disease-related factors and service-related factors.

Setting: 

The setting was an HIV/AIDS primary care clinic of a large, university-affiliated hospital.

Sample: 

The study sample consisted of 135 patients whose records indicated that they had successfully regained employment following disease-related job loss. A matched cohort of individuals with HIV/AIDS who had not regained employment was selected as a comparison group.

Data Collection: 

The data consisted of patient clinical records related to HIV/AIDS treatment and symptoms and services delivered. Statistical analyses consisted of descriptive statistics and analysis of variance (ANOVA).

Intervention: 

The majority of predictor variables were related to HIV/AIDS, such as CD4 cell count and length of time in treatment. However, the effects of one intervention were also included, the provision of mental health services.

Control: 

A matched comparison group was selected consisting of individuals with HIV/AIDS who had not returned to work following disease-related job loss.

Findings: 

Substance use disorders were more prevalent in those who had not achieved return to work. Those who had returned to work were more likely to have received mental health assessment and treatment.

Conclusions: 

Mental health services may serve as a gateway to return to work for many individuals with HIV/AIDS. In addition, identifying patients who are already being treated by the mental health team in order to assess their desire and ability to return to work is an important first step in increasing the effectiveness of a return to work program.

URL: 
http://www.tandfonline.com/doi/abs/10.1300/J187v03n03_07?journalCode=whiv20
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

A randomized controlled trial of supported employment among veterans with post-traumatic stress disorder

Authors: 
Diclementi, J. D., Ross, M. K., Mallo, C., & Johnson, S.
Year Published: 
2012
Publication: 
Psychiatric Services in Advance
Volume: 
63
Number: 
5
Pages: 
464-470
Publisher: 
American Psychiatric Association
Background: 

Post traumatic stress disorder (PTSD) is a potentially disabling mental illness that can cause occupational dysfunction. Although vocational rehabilitation is often prescribed for patients with PTSD, standard vocational services are far from adequate in helping them obtain and maintain competitive employment.

Purpose: 

This study is the first to examine the outcome of evidence-based supported employment for veterans with PTSD. Study addressed this gap in the field of rehabilitation research.

Setting: 

The setting for the study was the Tuscaloosa Veterans Administration Medical Center.

Sample: 

Veterans were eligible for the study if they had a diagnosis of PTSD, wee aged 19-60, were eligible for the VAMC Vocational Rehabilitation Program, were currently unemployed, were interested in competitive employment, and were planning to remain in a 100 mile radius of the Tuscaloosa VAMC for the 12-month duration.

Data Collection: 

Using intent to treat analyses and two tailed tests with significance set at p less than or equal to .05, researchers compared rates of competitive employment, as well as number of weeks , day and hours worked; gross wages earned from all sources; and gross wages earned from competitive jobs.

Intervention: 

Unemployed veterans with PTSD were randomly assigned to either individual placement and support (IPS) supported employment (N = 42) or a Veterans Health Administration Vocational Rehabilitation Program (VRP) treatment as usual (N = 43). Employment rates and occupational outcomes were followed for 12 months. IPS intervention involved several important features. For example, the IPS specialist was integrated into the clinical mental health or PTSD treatment team, carried out all phases of the vocational services, provided predominantly community based employment, had a caseload of no more than 25 clients, and provided continuous time unlimited follow along supports for vocational services.

Control: 

The VRP followed the standard care in place at the VMC, which included one or more of these components: routine prevocational testing and evaluation for all patients on referral to VRP, vocational rehabilitation therapy and provided a work regimen with monetary incentives, and a transitional work program that included a temporary work experience.

Findings: 

During the 12-month study, 76% of the IPS participants gained competitive employment, compared with 28% of the VRP participants (number needed to treat = 2.07; ?(2) = 19.84, df = 1, p<.001). Veterans assigned to IPS also worked substantially more weeks than those assigned to VRP (42% versus 16% of the eligible weeks, respectively; Mann-Whitney z test p<.001) and earned higher 12-month income (mean ± SD income of $9,264 ± $13,294 for IPS versus $2,601 ± $6,009 for VRP; Mann-Whitney z test p<.001) during the 12-month period.

Conclusions: 

Veterans with PTSD who received IPS were 2.7 times more likely to gain competitive employment than those who received VRP. Because work is central to recovery, these results should assist stakeholders in planning improved services for veterans with PTSD.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/22307881
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Do sheltered workshops enhance employment outcomes for adults with autism spectrum disorder?

Authors: 
Cimera, R., Burgess, S., & Wiley, A.
Year Published: 
2012
Publication: 
Autism
Volume: 
16
Number: 
1
Pages: 
87-94
Publisher: 
Sage
Background: 

Individuals with ASD have difficulty gaining access to vocational services to assist them with gaining and maintaining work. As a result some individuals go to a place known as a sheltered workshop. The main premise behind this approach is a person with a severe disability must have certain skills prior to going to work. An individualized approach to supported employment believes a person does not have to get ready to work. Instead a unique array of individualized supports are used to assist an individual with a severe disability with gaining and maintaining competitive employment in the community.

Purpose: 

This study examined whether or not participation in a sheltered workshop could help prepare individuals with ASD for competitive employment.

Setting: 

The study took place in sheltered workshop settings and a variety of businesses.

Sample: 

The study sample included 430 individuals with ASD; 215 were being served in a sheltered workshop setting, the others were not. These groups were matched based on diagnosis and sex (20%) were female and 80% male.

Data Collection: 

Data was collected on a number of variables using the RSA 911 database. This included: disability, wages earned, hours worked, and cost of services. Vocational rehabilitation counselors are required to keep this type of documentation. The rate of employment was determined by dividing the number of individuals who had their case closed due to an employment outcome by the total number of job seekers in that group.

Intervention: 

The intervention was sheltered work.

Control: 

Individuals who attended a sheltered workshop to prepare for competitive employment were compared to those who received supported employment services to gain and maintain competitive work.

Findings: 

Individuals who received supported employment services, earned significantly more ($190 vs $129) and had lower service cost ($2,441 vs $6,065) than those in sheltered workshops. Individuals with ASD do not need to participate in a sheltered workshop to get ready to work before receiving supported employment services. In addition, these individuals are underemployed.

Conclusions: 

Individuals with ASD will have better work outcomes if they receive supported employment services and bypass attending a sheltered work or other facility based program.

URL: 
http://aut.sagepub.com/content/16/1/87
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Service patterns related to successful employment outcomes of persons with traumatic brain injury in vocational rehabilitation

Authors: 
Catty, J., Lissouba, P., White, S., Becker, T., Drake, R., Fioritti, A., Knapp, M., Lauber, C., Rossler, W., Tomov, T., van Busschback, J., Wiersma, D., & Burns, T.
Year Published: 
2006
Publication: 
NeuroRehabilitation
Volume: 
21
Number: 
4
Pages: 
279-293
Publisher: 
IOS Press
Background: 

A number of cognitive, physical, and psychosocial impairments can occur following a TBI. These deficits can have a profound effect on daily functioning including an individual's ability to work. This may raise significant challenges for vocational rehabilitation professionals when helping individuals with TBI to prepare, obtain, and maintain competitive employment. Given the prevalence of TBI and the young age of many survivors, vocational rehabilitation will be needed. Professionals serving these individuals need to be prepared to develop appropriate rehabilitation plans. To be effective, they need to be familiar with TBI and the current research that looks at what impacts successful vocational outcomes. This may help facilitate the best use of limited funds for the vocational rehabilitation of persons with TBI. There are limitations in the research to date and more research is needed.

Purpose: 

The purpose of this study was to examine effects of demographic characteristics, work disincentives, and vocational rehabilitation services patterns through an analysis of the Rehabilitation Services Administration (RSA) case service report (RSA-911) data on employment outcomes of persons with traumatic brain injuries (TBI) for fiscal year 2004.

Setting: 

This study included individuals with TBI served by multiple vocational rehabilitation agencies in various settings.

Sample: 

The sample included 7,366 individuals with TBI whose cases were closed by state vocational rehabilitation agencies as employed or not employed in the fiscal year (FY) 2004.

This included 4,862 men (66%) and 2,504 women (34%). The majority or 78% were European Americans. The average age of participants was 37 years. Thirteen percent had co-commitment disabilities (psychiatric or substance abuse). Seventy six percent had a high school degree or more education. The average time between applying to eligible for VR services was a month and a half. The average time between eligibility and case closure was 30 months. Case expenditures averaged $4,238.

Data Collection: 

A data mining technique, exhaustive chi-squared automatic interaction detector (CHAID), was used to analyze. In the current study, exhaustive CHAID was used to build classification trees. This technique uses a systematic algorithm to detect the strongest association between predictors and the outcome variable (e.g., employment outcomes) through a comprehensive search of the predictors and the levels of predictors from the entire set that show the most differentiation on the employment outcome variable. The degree of differentiation is depicted sequentially in a decision tree format to show the optimally split predictors. Thus, homogeneous groups of vocational rehabilitation clients could be identified based on their demographic characteristics, work disincentives, and service patterns in terms of their observed levels on the outcome variable. The statistical software SPSS Answer Tree 2.0 was used to conduct the exhaustive CHAID analysis. The alpha level for all statistical tests was 0.01. This study corrected for the number of statistical tests within each predictor using a Bonferroni feature in the Answer Tree software.

Intervention: 

The interventions included various vocational rehabilitation services. This included job search assistance, job placement assistance, and on-the-job support services for individuals with TBI.

Control: 

There was no control or comparison condition.

Findings: 

The employment success rate for the entire sample was 50%. The employment success rate for persons with TBI is somewhat lower than the 55% rate for
the overall sample of vocational rehabilitation clients closed in FY 2004. European Americans had higher competitive employment rates than other groups. Clients with co-occurring psychiatric disabilities had a lower employment rate than those without psychiatric disabilities . Clients who had work disincentives also showed significantly poorer employment outcomes than those without disincentives. In terms of education, clients with a bachelor or higher educational degree had the highest competitive employment rate as compared to those with less education.

Case expenditure was related to outcomes, with more money spent on clients who were closed as successfully rehabilitated. Clients who were successfully rehabilitated also required less time in the rehabilitation process than unsuccessfully rehabilitated clients. Clients who received the following vocational rehabilitation services on-the-job training, job readiness training, miscellaneous training (e.g., GED or high school training needing to diploma), job search assistance, job placement assistance, on-the-job supports, maintenance, rehabilitation technology, and/or other services (e.g., occupational licenses, tools and equipment, and initial stocks and supplies) had significantly higher competitive employment rates than those who did not receive such services. Overall, the results indicated that the TBI clients could be segmented into 29 homogeneous subgroups with employment rates ranging from a low of 11% to a high of 82%, and these differences can be explained by differences in work disincentives, race, and rehabilitation service patterns.

Conclusions: 

Several vocational rehabilitation clinical practice guidelines came from the results of this study. First, the study underscore the importance of considering job placement and workplace support services in the vocational rehabilitation of persons with TBI. Unfortunately, job placement assistance and on-the job supports were found to be significantly underutilized by rehabilitation counselors in serving their TBI clients. Second, this study highlights the influence of disincentives on employment outcomes. Increased emphasis appears needed in the education of rehabilitation counseling students and practitioners on the importance of benefits counseling services and to encourage rehabilitation counselors to discuss this important service with consumers early in the rehabilitation planning process. Third, co-occurring psychiatric disabilities were found to significantly affect employment outcomes. This finding underscores the importance for rehabilitation counselors to (a) appropriately assess the emotional and psychological functioning of those served and to provide mental health counseling (b) increase knowledge about evidence-based mental health practices, and (c) to utilize the various interventions that have been found successful in diminishing psychiatric symptoms in the rehabilitation process. Finally, the very low incidence of co-occurring substance abuse disorders identified in this study (3%) is unusual, given research has indicated that about 50% to 66% of TBI clients had a history of alcohol and other drug abuse. This may be under reported. Rehabilitation counselors, need better education and training in substance abuse assessment and treatment within the context co-occurring disabilities.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/17361045
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Working it out: Development and testing of a multimedia, vocational education program

Authors: 
Campbell, K., Bond, G., & Drake, R.
Year Published: 
2004
Publication: 
Substance Use and Misuse
Volume: 
39
Number: 
13
Pages: 
2525-2558
Publisher: 
Marcel Dekker Inc.
Background: 

Employment is a ongoing problem for individuals with substance dependency. Their vocational needs are unmet. Earlier studies have shown a positive correlation between employment and retention in treatment. Despite evidence about the value of addressing employment issues in treatment, the service delivery system does not address these needs. Welfare reform has increased expectations for substance abuse beneficiaries to gain employment. Due to shorter stays and funding cuts more programs primarily focus on substance use. Employment and work problems are not given priority. A multimedia interactive computer program may offer a cost effective way to address employment problems.

Purpose: 

The study hypothesis was that an interactive and tailored multimedia presentation of vocational rehabilitation information would be more effective than a general printed package of information and work book in reducing the severity of employment problems.

Setting: 

The study took place in residential and outpatient services for substance misuse from six treatment facilities in Massachusetts, New Hampshire, Vermont, Rhode Island, and New Mexico.

Sample: 

One-hundred and ninety-four (194) individuals who received residential and outpatient services for substance misuse from six treatment facilities in Massachusetts, New Hampshire, Vermont, Rhode Island, and New Mexico participated in the study. The average age of participants was 37 years and the majority or 64% were men. About 43% were from a minority group.

Data Collection: 

The measures included the Addiction severity index-multimedia version (ASI-MV), Social adjustment scale-self report (SAS-SR), Employment questionnaire, Treatment services review and Satisfaction questionnaire. Around 75% of the sample completed 3 or more CD-ROM sessions. These participants completed a satisfaction questionnaire after each session and at the end entire course. Follow up assessment was scheduled 6 month from baseline. Subjects completed SAS-SR and Employment Questionnaire. They were also contacted by telephone to complete a follow up to the ASI.

Intervention: 

The intervention included: Working It Out CD-ROM, a multi-session, computer based, self-administered, vocational education and intervention program for clients in substance dependency treatment programs.

Control: 

There was a comparison between the group that received the intervention and the control group members. The control group members used the Looking for Work Printed Package booklet along with a workbook with information on: facing fears, why work?, coping with job-related stress, job-finding skills (writing a resume, networking, interviewing, etc.), caring for oneself and the job, and what to say about ones recovery.

Findings: 

The study demonstrated that a multimedia vocational rehabilitation program that is self-administered, interactive, and tailored to clients employment status and motivation can be used in a substance dependency treatment program. The study did not find significant differences over the use of printed versus multimedia material. However, clients reported enjoying using the computer program and found the experience more relevant to their particular concerns.

Conclusions: 

The multimedia Working It Out program can be effectively used by clients who are in substance dependency treatment.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/15603013
NIDILRR Funded: 
Peer Reviewed: 
Yes